Unsecured Medication Storage in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments as required by state and federal laws. During an observation, two packs of collagen powder, which was ordered for wound care, were found on a resident's bedside table rather than in a locked medication or treatment cart. The resident, who was cognitively intact and had a stage 4 pressure ulcer of the lower sacrum, stated she did not know who brought the collagen powder into her room. Multiple staff interviews confirmed that medications, including collagen powder, should not be left in resident rooms and should be stored securely in the nurse's or treatment cart. Staff were unaware of how the medication ended up in the resident's room, and it was noted that hospice staff may have left it there. The facility's policy requires that all drugs and biologicals be stored safely and securely in locked compartments, accessible only to licensed nursing personnel, pharmacy personnel, or authorized staff members. However, the observation and staff interviews revealed that this policy was not followed in the case of the resident with the pressure ulcer, as the collagen powder was left unsecured in the resident's room. This lapse in medication storage protocol was identified during the survey and confirmed through interviews and record review.